The RRC Mandate for Residency Programs to Demonstrate Psychodynamic Psychotherapy Competency Among...

Special Article

Academic Psychiatry, 29:4, September-October 2005 http://ap.psychiatryonline.org 339

The RRC Mandate for Residency Programsto Demonstrate Psychodynamic Psychotherapy

Competency Among Residents:A Debate

Joel Yager, M.D., Lisa Mellman, M.D., Eugene Rubin, M.D., Ph.D.Allan Tasman, M.D.

Received November 15, 2004; revised December 9, 2004; acceptedJanuary 13, 2005. Dr. Yager is with the Department of Psychiatry,University of New Mexico School of Medicine, Albuquerque, NewMexico. Dr. Mellman is with the Department of Psychiatry, Collegeof Physicians and Surgeons, Columbia University, and NY State Psy-chiatric Institute, New York, New York. Dr. Rubin is with the De-partment of Psychiatry, Washington University School of Medicine,St. Louis, Missouri. Dr. Tasman is with the Department of Psychiatryand Behavioral Sciences, University of Louisville School of Medicine,Louisville, Kentucky. Address correspondence and reprint requeststo Joel Yager, M.D., Department of Psychiatry/MSC09 5030, Uni-versity of New Mexico School of Medicine, 1 University of New Mex-ico, Albuquerque, NM 87131-0001; [email protected] (E-mail). Copy-right � 2005 Academic Psychiatry.

Objective: The Residency Review Committee (RRC) require-ment that residents must achieve competency in psychodynamicpsychotherapy has generated considerable deliberation.

Methods: The authors debated this subject at the 2004 Amer-ican Psychiatric Association (APA) meetings.

Results: Arguments favoring current requirements emphasizethe importance of psychodynamic psychotherapy for psychiatrictraining and practice, as essential skill and as part of core psy-chiatric identity. Opposing arguments, while supporting trainingin basic psychotherapeutic skills, focus on what some consider askimpy evidence base, competing time requirements, changingpractice patterns of psychiatry, and challenges to reliably andvalidly demonstrating this competency.

Conclusion: RRC decisions regarding current psychotherapycompetency requirements will appreciably shape future psychi-atric residency training.

Academic Psychiatry 2005; 29:339–349

The Accreditation Council for Graduate Medical Edu-cation (ACGME) has embarked on an outcomes pro-

ject requiring programs to attend to the development ofspecific competencies and to use information derived fromongoing assessment of these competencies to continuouslyimprove educational processes and the capabilities of pro-gram graduates. In 1999, the ACGME endorsed a planrequiring all residency programs, regardless of specialty, toassess residents for general competencies in six core areas:patient care, medical knowledge, practice-based learningand improvement, interpersonal and communicationskills, professionalism, and systems-based practice. Start-ing in 2001, the Residency Review Committee (RRC) forPsychiatry added specific requirements, as follows, in sec-tion VI.B.2, which focuses on “Internal Evaluation”:

The program must demonstrate that residents have achievedcompetency in at least the following forms of treatment:a. brief therapy; b. cognitive behavior therapy; c. combinedpsychotherapy and psychopharmacology; d. psychodynamictherapy; and e. supportive therapy. (1)

These well-intentioned requirements have generatedconsiderable controversy in the field. Regardless of howfavorably or unfavorably individual departments and train-ing directors perceive these requirements to be, the re-quirements have forced substantial local discussion andvariable efforts at implementation. Some psychiatric lead-ers have questioned the wisdom of these requirements,particularly regarding those psychotherapies for whichrelatively weak evidence-based research support now exists.Background information regarding the requirements andthe attendant disputes were published in a special issue ofAcademic Psychiatry in 2003 (vol. 27, no. 3). Recognizingthe controversies surrounding current recommendations,the APA Scientific Program Committee invited the authors

RRC MANDATE

340 http://ap.psychiatryonline.org Academic Psychiatry, 29:4, September-October 2005

to engage in formal debate at the May 2004 annual meet-ing, in New York City, which was framed around this is-sue—Resolved: The RRC should continue to require thatpsychiatric residency programs demonstrate that the resi-dents have achieved competency in psychodynamic psy-chotherapy.

Drs. Mellman and Tasman were asked to present forthe “pro” side. Dr. Mellman has been instrumental inhelping to define psychotherapy competencies for resi-dency training directors through her work in the Ameri-can Association of Directors of Psychiatric ResidencyTraining (AADPRT) and APA’s Task Force on Compe-tency in Graduate Education, and Dr. Tasman has ad-vocated for RRC requirements for psychotherapy com-petency through APA’s Commission on the Practice ofPsychotherapy by Psychiatrists and other venues. For the“con” side, Dr. Yager was asked to participate as a resultof the concerns he’d expressed about competency assess-ment in the special issue of Academic Psychiatry men-tioned above, and Dr. Rubin because of his vocal expres-sion of concerns at various AADPRT meetings in thepast. Debators were asked to organize their points intofirst and second presentations for each side, and to offersummary statements at the end.

The following narratives, condensed due to space limi-tations, provide the essence of these presentations and therespective arguments.

First Arguments Favoring Maintaining theCurrent RRC Requirements as Written:

Lisa Mellman, M.D

Residents should be trained to competency in psycho-dynamic psychotherapy (1, 2). It provides a unique modelof mental functioning that includes five key concepts,namely: 1) unconscious mental processes; 2) transference;3) countertransference; 4) defense and resistance; 5) thepast repeating itself in the present (3–5). In contrast, myopponents support a world in which psychodynamic psy-chotherapy is not taught to residents or is poorly taughtand not learned.

What would residency training be like without psycho-dynamic psychotherapy competency? First let us look atthe concept of the unconscious. Without an understandingof the unconscious, residents might just accept whateverpatients tell them at face value. For example, a residentuntrained in psychodynamic psychotherapy might simplyaccept that a patient “forgot” to call his boss on a sick day,resulting in his being fired, and might focus on strategies

for remembering to do things, such as using post-its. Butsuch a resident might not know to help the patient considerother reasons for forgetting that he was not aware of, suchas not liking his job, or his boss, or being angry that he didnot get the raise he requested. Residents would not con-sider that their patients, and even they themselves, are in-fluenced by motivations they are not aware of, such as un-conscious guilt or competitive strivings. They would noteven realize that they themselves have unconscious feel-ings toward their patients.

Second, what about transference? Without the conceptof transference, residents would not even know they arebeing idealized. They would believe that the patient thinksthey’re great because they’re really great. What a danger-ous power trip! They would not fully understand that theintensity of early life relationships is carried into the ther-apeutic relationship. Or they would not see it coming whenthe abused patient experiences them as abusive too. Trans-ference is a powerful concept that surprises even the mostskilled beginning therapists. What disservice it would be totrain residents without asking them to experience firsthand the importance and intensity of transference fromtheir patients toward them, and to be able to learn aboutit in supervision. Furthermore, should not residents learnthat patients still have transference to them as pharma-cologists? That patients have transference to the medica-tions residents prescribe? That these transferences influ-ence whether they take the medication? Residents need tolearn about transference in an ongoing therapy before theywill be able to see it elsewhere (6).

Third, countertransference. Do you not think it is a goodthing for residents to know why they keep forgetting to callthat one patient back? Or to even recognize that when thepatient talks about anger, they, the therapist, changes thesubject? Psychiatrists must tolerate many affects of theirpatients but also so many of their own. Residents who donot learn that countertransference provides a window intounderstanding the patient, and that it helps therapistsknow their blind spots, will try to squelch these reactionsrather than become curious about them. Psychodynamicpsychotherapy teaching gives residents ways to turn in-tense and painful experiences into data that can be ob-served and understood.

Fourth, defenses and resistances are ubiquitous in all ofus, including patients and therapists. They protect us fromdiscomfort, yet reveal information about affects and de-sires. Should not a resident know that when the patientcomplains that the room is too cold, the patient may beusing displacement to avoid saying he thinks the resident

YAGER ET AL.


acts coldly? Should not a resident be curious to understandwhy that exasperating subway makes the patient late mostsessions, as though the patient has no control over beinglate? Without the concept of defense and resistance, ourresidents will not appreciate how desperately we all try tohide the truth from ourselves. Nor will they appreciate thesubstantial changes that a patient can make from learningto identify and explore defenses and the affects and objectrelationship patterns they defend against.

Fifth, the past repeats itself in the present. This concept,recently borrowed from the psychodynamic tradition bySchema therapy, a long-term form of cognitive behaviortherapy, emphasizes exploring past relationships and find-ing patterns that are repeated in one’s current life (7). Whydoes Ms. Poe continue to fall for men who are losers? Itis frustrating for residents to learn that patients can stayentrenched for a long time in maladaptive relationshipsand patterns of behavior. And it is incredibly gratifying toresidents to work with patients long enough to see thesepatterns change. I believe residents need to be trained inpsychodynamic therapy to really understand the pervasive-ness and stickiness of this concept that Freud called therepetition compulsion.

My opponents will argue today that psychodynamic psy-chotherapy lacks evidence for efficacy and effectiveness.Dr. Tasman will debunk this myth. There is evidence, andit is growing.

My opponents may also say that psychodynamic therapyis too hard to teach and that competency is too difficult tomeasure. They may say that competency in psychodynamicpsychotherapy is a postresidency competency, that there isnot enough time to teach it in residency, that programslack the resources (2).

Let me address the following points:1. Psychodynamic psychotherapy is too hard to teach.

Yes, teaching psychodynamic therapy requires didacticteachers, suitable patients and trained supervisors (8). Weknow that residents learn psychodynamic psychotherapy inthose programs that are considered to be the best pro-grams nationally. This requires commitment from the de-partment to use resources to develop a sufficient teachingprogram (9).

2. Let us discuss competency. According to the ACGME,competency is a level of skill midway between beginner andmaster (10). What is psychotherapy competency at the pointof graduation from psychiatry residency? Competency atgraduation should minimally include that residency gradu-ates be capable of conducting psychotherapy but that theybe expected to grow in knowledge and proficiency with

further education, practice and supervision (3) and thatthey be able to utilize the concepts I mentioned earlier—unconscious, transference, defense, countertransference ina treatment—to recognize them when they appear and beable to further explore them.

3. Why should we train to a level of competency? With-out a standard of competency the field will set the bar onlyat the level of skill acquisition that programs can alreadyachieve. In some, that would mean having no patients atall in psychodynamic therapy. The competency movementhas forced the education field to rethink its goals and toshift from a cafeteria model of Food Sampling to a modelof Food Metabolism. Now we need to measure how theresident has actually metabolized the course or rotationand measure what they have actually digested. Standardsand accountability are good for our field. Already, trainingdirectors are evaluating where they have set the bar, andwhere it should be reset.

4. Let us now discuss measuring competency. This is acomplex issue since there is no gold standard (11). Wemust appreciate that the field hasn’t yet established howto set and evaluate competency in psychopharmacology ei-ther. However, several methods for evaluating competencyin psychotherapy include supervisor evaluations assessingpsychodynamic therapy competencies, case write-ups re-viewed for understanding of process and technique, oralpresentations at seminars where attitudes can especially begleaned, the Columbia Psychodynamic PsychotherapyTest, video and audio tapes (12), and assessment of processnotes (13, 14).

Teaching psychodynamic psychotherapy to competencyis psychiatry’s “no child left behind” policy. What is thealternative? Not teaching psychodynamic therapy or notteaching it to competency? No program, and no resident,should be left behind.

First Arguments Opposed to Maintaining theCurrent RRC Requirements as Written:

Eugene Rubin, M.D., Ph.D

The topic of this debate is whether our field should con-tinue the requirement that psychiatry residency trainingprograms demonstrate that residents have achieved com-petency in psychodynamic psychotherapy. I want to makeclear that both Dr. Yager and I strongly believe that it isimportant that residents receive psychotherapy trainingand psychotherapy experience. We also support residentsreceiving didactics and experience dealing with psychody-namic concepts. This debate deals with the issue of ele-

RRC MANDATE


vating psychodynamic psychotherapy to a special level ofdistinction by creating a separate competency requirementfor this technique.

Our position is that a competency requirement in psy-chodynamic psychotherapy is not in our field’s best inter-est. This opening statement will revolve around two basicthemes. The first deals with flexibility—flexibility to in-corporate new, rapidly accumulating, clinically relevantknowledge and flexibility to teach our residents the toolsnecessary for lifelong learning. Developing true compe-tency in psychodynamic psychotherapy is time consuming,and any individual treatment modality would need strongevidence-based support to justify this expenditure of time.Time devoted to one area detracts from time spent in otherareas. We need to ensure that residency programs main-tain the flexibility to teach residents the knowledge nec-essary to follow future advances (15).

The second theme deals with issues of credibility. Howcredible do we appear if we are spending a large amountof time on a specific treatment modality, psychodynamicpsychotherapy, that has limited evidence of support? Letme repeat: we strongly feel that residents should under-stand and be comfortable administering psychotherapiesto their patients. We must be aware, however, that thereare an increasing number of evidence-based, effective psy-chotherapies, and residents are not going to have time tobecome competent in each. Rather, it is important for res-idents to learn the common elements underlying all psy-chotherapies and to understand the process of psycho-therapy by having in-depth experience in one or moreevidence-based therapies. In-depth experience is differentfrom true competency, however. In addition, residentsmust understand the risks and benefits as well as the in-dications of all evidence-based psychotherapies. Some pa-tients will benefit best from an extensive course of a par-ticular formal psychotherapy, and some psychiatrists willelect to provide this formal psychotherapy themselveswhile others will coordinate this care with other teammembers.

There have been concerns that psychiatry has movedtoward too heavy an emphasis on psychopharmacology.There is no question that we need to integrate both so-matic and psychotherapeutic approaches. However, wehave to be careful that we do not overreact to a concernabout too heavy an emphasis on psychopharmacology byrequiring competency in psychodynamic psychotherapy.

I have mentioned that flexibility is needed in order toallow programs the time to teach about clinically relevantscientific advances, as well as the tools necessary for life-

long learning—tools derived from genetics, genetic epi-demiology, epidemiology, neurosciences, imaging, cogni-tive sciences, and other areas (e.g., 16), advances that arerelevant today or will be over the next several years. Forexample, Dr. Eric Kandel notes that we are entering intoan era of “a new, biologically inspired personalized med-icine” (17). We will increasingly have the ability to choosethe most appropriate treatment for a specific individualbased on that individual’s genetic makeup, propensity forside effects, and even individual risk that a particular drugmay result in substantial weight gain (18).

Another rapidly advancing area with clinical relevanceinvolves imaging. Thanks to new processes for imaging am-yloid in humans in vivo (19), we will shortly be able todetect preclinical Alzheimer’s disease in individual pa-tients, predict who is developing this illness, and preventor greatly slow down its development.

We are learning that new neurons are generated in thedentate of the hippocampus throughout life (20), relevantto psychiatrists since medications we use, including moodstabilizers and antidepressants, have substantial influenceon the survivability and interconnectivity of these cells. Afinal example from the field of cognitive sciences involvesrehabilitative psychosocial approaches applicable to pa-tients with schizophrenia. Capitalizing on knowledge thatcertain memory processing skills are stronger than othersin patients with schizophrenia, researchers have demon-strated that schizophrenic patients can be more effec-tively taught work-related skills with a high degree of suc-cess (21).

Where do we get time to teach all these developmentsand many more? Insisting that psychodynamic psycho-therapy must be mastered to the level of competence putssignificant time pressures on residency programs. Re-quiring time-consuming competency in psychodynamicpsychotherapy discourages flexibility in an environmentwhere competition for educational time is severe. Othersagree, however. The Institute of Medicine’s recent reportentitled “Research Training in Psychiatry Residency”stresses the need to increase flexibility of psychiatry res-idency training (15).

The second theme involves credibility. The U.S. popu-lation is growing, and the number of psychiatrists leavingthe field due to retirement or death matches or exceedsthe number entering the field. Consequently, the shortagethat already exists will increase. If psychiatrists were to in-crease their practice of long-term psychodynamic psycho-therapy, access to psychiatrists would be further limited fora large number of very sick patients. Society’s needs should

YAGER ET AL.


be our field’s major focus. Certainly, psychiatrists musthave excellent clinical skills. However, competency in psy-chodynamic psychotherapy, as opposed to experience withpsychodynamic techniques, is not required to administerfirst-rate care.

How can we justify to the public that we are spending asubstantial amount of time teaching residents to be com-petent in a technique that has limited evidence of efficacyand, if formally practiced by most psychiatrists, takes timeaway from teaching current advances and would decreaseour ability to treat the large number of patients requiringour skills? How can National Alliance for Research onSchizophrenia and Depression (NARSAD), National Al-liance for the Mentally Ill (NAMI), and the Depressionand Bipolar Support Alliance (DBSA) champion us if wecontinue in this direction?

Our past has been fascinating and our future will beextraordinary (22). To remain relevant and “cutting edge,”we need to be both flexible and credible. This is the veryessence of the discussion we are having at this debate.

Second Arguments Favoring Maintaining theCurrent RRC Requirements as Written and

Response to Dr. Rubin:Allan Tasman, M.D.

Dr. Rubin’s arguments focus on several issues. He ar-gues that singling out psychodynamic psychotherapy to aseparate level of distinction is inappropriate, that requiringcompetency in psychodynamic psychotherapy severelycompromises training flexibility in other areas, and thatfocus on psychodynamic psychotherapy—with the asser-tion of its limited effectiveness—leads to a lack of credi-bility. Further, he suggests that if most psychiatrists prac-tice psychodynamic psychotherapy, we would be unable totreat the large number of patients with severe psychiatricillnesses needing treatment. Let me respond to each point.

Competency CertificationResidency directors must certify that residents, at the

completion of training, are competent to practice psychi-atry. This attestation, a requirement for residents to sit forAmerican Board of Psychiatry and Neurology exams, isuniversally interpreted to incorporate all required areas ofthe residency review committee (RRC) criteria, not justpsychotherapy. While RRC requirements specifically high-light required competencies in five areas of psychotherapythe expectation is that residents will demonstrate broadcompetency in clinical practice. Training residents to com-

petently evaluate suicide risk is time intensive, but no oneargues that we should compromise expectations that resi-dents achieve competence in these evaluations. The sameholds for essentially every aspect of clinical practice.Learning to be a competent practitioner is time-consum-ing. Further, competency in psychotherapy is embodied incriteria for successfully completing Part 2 of the ABPNexamination.

Dr. Rubin also argues that “a competency requirementin psychodynamic psychotherapy is not in our field’s bestinterest.” He argues that if we devote time to this area, wewill lack time for others. It is tautological to argue thattime spent on one area is time unavailable to other areasof training. Why does Dr. Rubin single out psychodynamicpsychotherapy for different treatment? He argues that ittakes too long to teach or learn it. I fear this reflects thezeitgeist of the ultrafast-paced world of sound bites andfactoids where everything must be learned quickly.

FlexibilityI agree that we must maintain flexibility to teach resi-

dents knowledge necessary to follow future advances. Hehighlights two areas, genetics and brain imaging, as ex-amples. I agree that genetics is extremely important. Not,however, a simplistic form of genetics. We must teach abroader view of genetics including clear understanding ofinteractions between genetics and environment on devel-opment. Dr. Rubin cites Dr. Eric Kandel’s work to justifyhis viewpoint. Please understand that Dr. Kandel wouldvery likely support my perspective in that he clearly rec-ognizes that developmental stress and experiences influ-ence genetic expression. His Nobel Prize was based on justsuch a discovery. Therefore, studying modulation of brainfunction through psychotherapeutic techniques offers tan-talizing future opportunities for better understanding howpsychotherapy influences genetic expression.

Dr. Rubin highlights research regarding diminished hip-pocampal neuronal generation in depression but does notmention the association found between chronic stress andsuppression of hippocampal neuronal growth. The fact isthat successful psychotherapy leads to more adaptivethinking and behavioral patterns, ameliorates stress, andcan prevent previously stressful experiences from havingsignificant effects on the individual. Thus, psychodynamicpsychotherapy has significant pertinence to the role of hip-pocampus in depression. Finally, Dr. Rubin highlights ad-vances in braining imaging. Over 20 years ago, Eric Kandelhimself wrote that someday imaging techniques would be-

RRC MANDATE


come sophisticated enough to demonstrate the effective-ness of psychotherapy in altering brain function (23). Weare on the threshold of such ability. None of these argu-ments support eliminating psychodynamic psychotherapycompetency from the armamentarium of future psychia-trists.

CredibilityDr. Rubin argues that teaching psychodynamic psycho-

therapy competence is not credible, as he asserts lack ofan evidence base supporting its effectiveness. The Instituteof Medicine’s report on evidence-based medicine notesthat evidence includes both formal research studies andclinical experience (15). Psychodynamic psychotherapymeets both criteria. Well-conducted meta-analyses andcritical reviews involving scores of studies using psycho-dynamic psychotherapy suggest that this approach is effec-tive and usually comparable to other psychotherapies (24).Additionally, thousands of clinical reports support the roleof psychodynamic psychotherapy in symptom relief andresolution of psychological problems.

Dr. Rubin also maintains that we lose credibility if sig-nificant numbers of psychiatrists would not treat severelyill patients because they practiced psychodynamic psycho-therapy. In reality, studies by APA Psychiatric ResearchNetwork indicate that caseloads for psychiatrists nationallyare heavily weighted toward severe psychiatric illnessesand that the same psychiatrists indicate that psychotherapyis a significant part of their overall practice. Thus, this ar-gument is easily dismissed. Training residents to compe-tence in psychodynamic psychotherapy does not causethem to focus on a therapeutic intervention with limitedevidence for efficacy. Nor does it impede our treating largenumbers of patients with severe psychiatric illnesses.

Arguments in support of requiring psychodynamic psy-chotherapy competence go well beyond those Dr. Rubincriticizes. A still relevant article, published in 1990 in TheAmerican Journal of Psychiatry, that I coauthored listedmany important reasons to continue teaching psychody-namic psychotherapy (25). Some of these reasons pertainto learning the skills and knowledge base necessary to com-petently practice psychodynamic psychotherapy, but sev-eral address other significant areas of training. These rea-sons include:

1. Concepts of psychodynamic psychotherapy are inti-mately related to the psychosocial underpinnings of alldoctor-patient relationships. Psychotherapeutically com-petent psychiatrists should be able to provide more effec-tive consultation to medical colleagues and manage their

own nonpsychotherapy doctor-patient relationships moreeffectively.

2. Psychotherapy training enhances learning about man-aging other dyadic relationships such as supervision, con-sultation, and mental health administration.

3. Psychotherapy training enhances basic interviewingexpertise by providing opportunities to observe longitudi-nally the course of psychopathological and normal mentalphenomena present in an initial interview. This enablesresidents to recognize emerging mental phenomena ear-lier, more accurately, and more confidently.

4. Psychotherapy training provides residents with in-depth and longitudinal understanding of both consciousand unconscious normal or pathological mental function-ing, related to efforts to change thinking, feeling, and be-havior. Such efforts require ongoing relationships betweentherapist and patient and involve inevitable obstacles, re-sistances, strengths, and clinical opportunities for under-standing these phenomena, essential to managing virtuallyall psychiatric disorders.

5. Psychotherapy provides observations of complexpathological and normal mental functioning over time,complementing observations of similar mechanisms in in-patient, consultation, and emergency room settings. Fur-thermore, it provides access to primary materials on whichpsychodynamic theory is based. As such, psychotherapytraining enhances learning psychodynamics as a basic sci-ence within psychiatry.

6. With its emphasis on the complex dyadic emotionalinterplay between psychiatrist and patient, psychodynamicpsychotherapy training enhances psychiatrists’ ability toanticipate, analyze, and manage their feelings toward pa-tients and avoid ethical dilemmas and transgressions.

7. Finally, psychotherapy training forces residents to ob-serve, analyze, and attempt to understand extremely com-plex interactive phenomena. This enforces intellectualrigor and discipline in observing behavior, developing hy-potheses, and analyzing theories and data.

Even if uncertainties exist about the role psychother-apy will play in psychiatrists’ future practices, these issueshighlight the importance of psychodynamically compe-tent training. There is little evidence that these lessonsof psychodynamic psychotherapy training can easily belearned in other ways. I doubt that residency programsdevote adequate attention to these issues outside of tra-ditional psychodynamic psychotherapy training.

In addition, competent psychopharmacology practice,highlighted by Dr. Rubin, requires outstanding skills inpsychodynamic psychotherapy. When a patient says “I’m

YAGER ET AL.


not taking my medicine anymore,” psychotherapeutic skillsare necessary to understand the patient’s motivations. Apsychiatrist at that moment must understand psychologicaldefense, transference, countertransference, and symbolicmeanings in the patient’s decision and be able to listenempathically while maintaining a productive therapeuticalliance. We know that the medication prescriptions em-body several meanings for patients. One is embodied inthe “illness belief system,” i.e. to what causes patients at-tribute their illnesses. Second, medications themselves mayhave symbolic meanings to patients, easily distorted by se-verely ill patients. Finally, patients attribute meaning topsychiatrists’ decisions to prescribe medications. The bestpharmacotherapy requires competence in assessing theseaspects of medication treatment as well as all other aspectsof clinical pharmacology.

In closing, I’ll return to the issue of genetics that Dr.Rubin raised. I believe our greatest future challenge willbe to more fully understand interactions between our ge-netic makeup and the impact of developmental experi-ences. The lack of 100% concordance in schizophreniaamong monozygotic twins, for example, could reflect sub-tle developmental difference between siblings. Our abilityto understand and modulate the impact of these differ-ences will continue to be essential to psychiatrists’ futureroles, enacting true biopsychosocial practice, and wouldrequire competence in psychodynamic psychotherapy.

Second Arguments Opposing Maintaining theCurrent RRC Requirements as Written and

Response to Drs. Mellman and Tasman:Joel Yager, M.D.

Dr. Rubin focused on whether we should require com-petencies in psychodynamic psychotherapy. In contrast, I’llfocus on whether such competencies could actually beachieved and reliably and validly assessed during resi-dency. Briefly, No. First, from a 1947 meeting supportingthe scientist-practitioner model of clinical psychology: “Wehave left therapy as an undefined technique which is ap-plied to unspecified problems with a nonpredictable out-come. For this technique we recommend rigorous train-ing” (26). Sadly, for psychodynamic psychotherapy thissituation hasn’t changed much since.

Again, we certainly don’t oppose psychodynamic psy-chotherapy training. We oppose the current RRC wordingspecifying that programs “must demonstrate that residentshave achieved competency in . . . psychodynamic psycho-therapy” (27). This requirement is misguided because as

stated it is unachievable with available time, personnel andassessment methods; encourages training directors to acthypocritically; and subjects programs to potential litiga-tion. Moreover, better wording could preserve the under-lying good intentions.

Semantic ConsiderationsWhat does professional “competency” mean to you?

Competence-based educators (28) have dummied downthe definition to demonstrate all sorts of “competencies”for educational and professional accountability (29–31).Whereas counting to 100 might constitute an early “mathcompetency,” you would not consider this to representCompetence in math. Most professionals—and laymen—reject trivial definitions, preferring to believe that “com-petency” actually signifies proficiency in performing ameaningful procedure. For competency in psychodynamicpsychotherapy, demonstrating mastery over a small subsetof knowledge or skills—“formative competencies” in edu-cational jargon—such as defining transference or demon-strating (through carefully selected moments of videotape)a therapeutic alliance, or describing aspects of therapeuticinteractions does not come close to assuring possession ofcomprehensive skills needed to really perform psychody-namic psychotherapy competently from start to finish forthe usual spectrum of clinical problems for which it is used.Demonstrating an array of small, measurable “competen-cies” (little “c”s) does not add up to actual Competency (abig “C”). Consider: when you need coronary bypass sur-gery, will you be satisfied simply knowing that your surgeonhas satisfactorily mastered some “formative competen-cies”—passing tests on anatomy and suturing? We doubtit. You’ll expect Competency (big “C”)—that your surgeonhas capably performed this complex surgery from begin-ning to end. Competency for psychodynamic psychother-apy should convey similarly high expectations, not neces-sarily for “masters” or “experts,” but certainly better thannovices.

Resources Will Be Insufficient to Meet theRequirement

Medicine teaches by “see one, do one, teach one.” But,although residents may observe slices of psychodynamictherapy in training, probably none ever observes severalcases treated from start to finish. How are trainees tomodel or reflect on expert performances?

Furthermore, educators suggest that multiple assess-ments of defined skills in different situations are necessaryto assure assessment validity (the number eight has beenmentioned) (32–34). How many residents anywhere con-

RRC MANDATE


duct this number of psychodynamic psychotherapies ob-served by supervisors? Have any of you observed residentsconduct a therapy from start to finish?

Next, since most therapy training occurs during PGY 3and 4, performance problems may be impossible to re-mediate within this time-course. What consequenceswould ensue if by the end of training residents fail toachieve psychodynamic psychotherapy competency?

Finally, programs lack enough time for trainees toachieve competency in psychodynamic psychotherapy.Even advocates agree that this competency is a develop-mental process that requires time; some suggest at least 2years following residency to “consolidate” psychotherapyskills and even start feeling “competent.” This impressionwas verified by graduates from strongly psychodynamicprograms, interviewed by Tanya Luhrmann for her excel-lent book, Of Two Minds (35).

Current Methods Are Inadequate for Reliably andValidly Assessing This Competency

Although we lack agreement on exactly what constitutespsychodynamic psychotherapy competency, Drs. Mellman,Beresin and others have provided an excellent start, defin-ing competency through a body of knowledge and 14 spe-cific skills (see Appendix 1) (36). However, we lack waysto reliably and validly assess these skills. The Psychody-namic Psychotherapy Competency Test (37, 38) falls shortof testing any of the 14 in a manner that serious evaluatorswould accept as sufficient for certifying Competence. Us-ing paper case vignettes and multiple-choice questions totest abilities to conceptualize psychotherapy interactionsand appropriate psychotherapeutic responses, this testmay assess residents’ intellectual grasp of basic conceptsbut shows nothing about what they would do in actualpractice. And we know that clinicians’ responses to paper-and-pencil vignettes does not necessarily represent theiractions when facing those situations in practice (39). Fur-ther, research shows how difficult it is to reliably and va-lidly test “live” psychotherapy skills (40). Experienced su-pervisors independently rated residents’ videotapedpsychotherapy interviews using a detailed instrument. In-terrater agreement was uniformly low and significantlypoorer for judgments about techniques than communica-tion skills, suggesting that methods purporting to assesspsychotherapy skills require careful methodological testingbefore acceptance as reliable and valid. Bottom line: westill cannot demonstrate criterion, concurrent, discrimi-nant, and/or predictive validity for most psychodynamic-process formative competencies.

Forcing Programs to Comply Will InevitablyGenerate Dishonesty in Training Directorsand Faculty

Unrealistic, arbitrary rules set by authorities inspiremanagers to develop ingenious, often hypocritical methodsfor meeting the letter—but not the spirit—of these rules(41). This misguided RRC requirement has already fos-tered patchwork solutions that are clearly more show thansubstance. Ultimately, the RRC will be forced to acceptprogrammatic charades for certifying this competency or,alternatively, “get real” about the requirement. Trainingdirectors must dissemble to certify unverifiable competen-cies. Ask yourself: “How honestly could I have certifiedthat every graduate from my program achieved big ‘C’competency in psychodynamic psychotherapy?”

Under Current Requirements Training Directorsand Programs Potentially Risk PunitiveAdministrative Actions and Litigation

In an increasingly litigious world psychiatrists who aresued for incompetent practice, and their patients, may de-cide, in turn, to sue the training programs for failing toassure required competencies. A prescient licensing boardfor psychologists states “candidates are not expected to becompetent in all or even almost all areas. . . . Psychologistsare expected to practice within their areas of competency.Future complaints against a psychologist who is practicingin an area that was not an area of competency when li-censed will place a general burden of proof of competenceon the psychologist in addition to the specific issues of thecomplaint” (42). Legally, you are held accountable to stan-dards you set.

Better Ways Exist to Fulfill the Requirement’sIntentions

Showing greater realism, one Canadian residency pro-gram states “residents are expected to develop both a basiclevel of proficiency in all modalities of psychotherapy andcompetency in at least one” (43). (By the way, what’s “pro-ficiency”?)

We suggest that the RRC rethink its current languageand recast requirements more realistically, as, for example:“Residency programs must show that all residents candemonstrate knowledge about the evidence base, theoriesand rules of practice supporting at least the followingforms of treatment. . . . In addition, programs must dem-onstrate by means of patient logs, taped recordings andother documentation that all residents have conducted[specify types, numbers and durations of psychothera-pies] . . . under qualified supervision.”

YAGER ET AL.


Summary of the Positive Position:Allan Tasman, M.D.

The primary argument supporting psychotherapy com-petency pertains to its value as an important, effective psy-chiatric treatment intervention, no less valuable than anyother accepted form of treatment. The negative positionasserts that psychodynamic therapy has little supportingevidence base. This argument is easily dismissed by largenumbers of research studies and thousands of publishedcase reports. They also argue that such training is too timeconsuming, but this case could be made for any aspect ofclinical practice. Further, the argument that requiring psy-chodynamic psychotherapy competency leads to psychia-trists in practice not seeing severely ill patients is belied byevidence collected from contemporary practitioners.

The final criticism relates to competency attestation.Over 20 years ago, Yager and Borus argued for higherquality standards in psychiatric residency training. Estab-lishing such requirements, they asserted, would requireprograms to take steps to measure quality education andassess program quality for accreditation purposes (44). Dr.Yager seems to have abandoned his wish for quality byessentially arguing that since we do not yet know how todefine competency or measure it, we should not expectanyone to require it. Without requiring demonstrations ofcompetency, improved quality will be impossible to reach.

The RRC recognized difficulties in defining and measur-ing competency when they established these requirements.They recognized that establishing this criteria would requiredeveloping new curricula and new methods for evaluatingcompetency in several areas. (The ACGME’s overall com-petencies were also established without adequate methodsin place for demonstrating these competencies. These re-quirements were also implemented with expectations thatimplementation of the requirements would stimulate thedevelopment of measures to assess competencies as well asthe associated curricula.) The same expectations shouldhold for training in psychodynamic and other psychothera-pies, and other areas of psychiatric practice.

Of course we must teach a vast array of knowledge andskills. But it is also true that most therapeutic transactionsin psychiatry will continue to occur in the context of dyadicphysician-patient relationships. Furthermore, patientshave not suddenly lost the capacities for symbolic meaningor to suffer from the vagaries and vicissitudes of devel-opmental conflicts and developmental deficits just becausewe are learning about genetics and biology of brain func-

tion. If we expect to maintain and improve our clinicalexcellence, we must rededicate ourselves to these psycho-dynamically based issues. I can think of nothing more im-portant to ensure continued excellence for our educationaland clinical enterprise.

Summary of Negative Position:Joel Yager, M.D

We are not against psychodynamic therapy, nor are weagainst training in psychodynamic therapy. But do not con-fuse support for psychodynamics with specific regulationsrequiring that programs demonstrate that all graduates haveachieved competency in psychodynamic psychotherapy—that is very different.

The ACGME’s requirements for competency-basededucation concern Patient Care; Medical Knowledge;Practice-Based Learning and Improvement; Interpersonaland Communication Skills; Professionalism; and Systems-Based Practice—none specific procedures. We should notrequire Competency for psychodynamic psychotherapy be-cause we cannot reliably agree on what it should be inpractice and haven’t specified the clinical problems forwhich its competence should be demonstrated. We lack thetime, resources and methods to train up to, remediate ifnecessary, and reliably and validly assess Competency dur-ing residency. Formative skills do not assure summativeCompetency. To meet the requirement, programs will triv-ialize the meaning of “competency” and/or dissemble. Fur-thermore, psychotherapy training can still be supported byrequiring supervised training in the concepts, tactics andpractice of useful psychotherapeutic strategies, requiringthat residents demonstrate knowledge about theories andpractices of these strategies and have documented super-vised experience, and having the RRC monitor these re-quirements.

Conclusion

Although no formal follow-up to this APA debate isplanned, the field as a whole will continue debating theseissues in several educational and political venues. We allhope that efforts devoted to psychiatric training and as-sessment will produce ever-improved methods for edu-cating and assessing our residents and for increasing theirprofessional proficiencies. How details are worked outwill be up to psychiatry’s talented array of educators andinfluence-leaders.

RRC MANDATE


APPENDIX 1. Suggested Core Competency Skills for Psychodynamic Psychotherapy

1. The resident will be able to evaluate the capacity of the patient to engage in and utilize psychodynamic psychotherapy.2. The resident will be able to display effective interpersonal skills in building and maintaining a collaborative therapeutic alliance that

promotes self-reflection and inquiry into the patient’s inner life.3. The resident will be able to establish treatment goals with the patient.4. The resident will be able to establish a treatment frame with the patient.5. The resident will be able to engage the patient in exploring his/her history of experiences, sociocultural influences, relationship patterns,

coping mechanisms, fears, traumas and losses, hopes and wishes in order to understand the presenting problems.6. The resident will be able to effectively listen to the patient to understand nuance, meanings, and indirect communications.7. The resident will be able to recognize and identify affects in the patient and himself/herself.8. The resident will be able to recognize, utilize and manage aspects of transference and countertransference, defense and resistance in

the course of treatment.9. The resident will be able to utilize self-reflection to learn about his/her own responses to patients to further the goals of the treatment.

10. The resident will be able to utilize clarification and confrontation.11. The resident will be able to utilize interpretation to manage transference/countertransference that impedes or disrupts the therapeutic

process.12. The resident will be able to manage and understand the meanings of termination.13. The resident will be able to write a psychodynamic formulation.14. The resident will be able to seek appropriate consultation and/or referral for specialized treatment.

From Mellman L, Beresin E. Psychotherapy competencies: development and implementation. Acad Psychiatry 2003; 27:149–153

References

1. www.acgme.org/RRC/Psy_Req.asp2. Mellman L, Beresin E: Psychotherapy competencies: devel-

opment and implementation. Acad Psychiatry 2003; 27:149–153

3. Gabbard G: Long-Term Psychodynamic Psychotherapy: A Ba-sic Text. Arlington, Va, American Psychiatric Press, 2004

4. Wallerstein RS: The future of psychotherapy. Bull MenningerClin 1991; 55:421–443

5. McWilliams N: Psychoanalytic Diagnosis. New York, Guil-ford, 1994

6. Tasman A: Presidential address: the doctor-patient relation-ship. Am J Psychiatry 2000; 157:1763–1768

7. Young J, Klosko J, Weishaar M: Schema Therapy. New York,Guilford, 2003

8. Weeresekera P, Antony M, Bellissimo A, et al: Competencyassessment in the Mcmaster psychotherapy program. AcadPsychiatry 2003; 27:166–173

9. Goldberg DA: Structuring training goals for psychodynamictraining. J Psychotherapy Prac Res 1998; 7:10–22

10. ACGME: ACGME Outcome Project: General Competen-cies, 2001. http://www.acgme.org/outcome/comp/comp-Full.asp (accessed May 12, 2004)

11. Bienenfeld D, Klykylo W, Lehrer D: Closing the loop: assess-ing the effectiveness of psychiatric competency measures.Acad Psychiatry 2003; 27:131–135

12. Lane JL, Gottlieb RP: Improving the interviewing and self-assessment skills of medical students: is it time to readoptvideotaping as an educational tool? Ambul Pediatr 2004;4:244–248

13. Summers R, Barber J: Therapeutic alliance as a measurablepsychotherapy skill. Acad Psychiatry 2003; 27:160–165

14. Cooper EM, Mellman LA, Kramarsky: Symptoms, defensesand the therapeutic alliance: findings after one year of psy-

chodynamic psychotherapy. J Am Psychoanal Assoc 2004;52:452–453

15. Abrams MT, Patchan KM, Boat TF (eds): Research Trainingin Psychiatry Residency, Strategies for Reform. Washington,DC, Institute of Medicine: National Academies Press, 2003

16. Caspi A, Sugden K, Moffitt TE, et al: Influence of life stresson depression: moderation by a polymorphism in the 5-HTTgene. Science 2003; 301:386–389

17. Kandel ER: Genes, brains, and self understanding: biology’saspirations for a new humanism. P&S, The Journal of Colum-bia University College of Physicians and Surgeons 2001 (fall);24–29

18. Reynolds GP, Zhang Z, Zhang X: Polymorphism of the pro-moter region of the serotonin 5-HT2C receptor gene and clo-zapine-induced weight gain. Am J Psychiatry 2003; 160:677–679

19. Klunk WE, Engler H, Nordberg A, et al: Imaging brain am-yloid in Alzheimer’s disease with Pittsburgh compound-B.Ann Neurol 2004; 55:306–319

20. Santarelli L, Saxe M, Gross C, et al: Requirement of hippo-campal neurogenesis for the behavioral effects of antidepres-sants. Science 2003; 301:805–809

21. Kern RS, Liberman RP, Kopelowicz A, et al: Applications oferrorless learning for improving work performance in personswith schizophrenia. Am J Psychiatry 2002; 159:1921–1926

22. Rubin EH, Zorumski CF: Psychiatric education in an era ofrapidly occurring scientific advances. Acad Med 2003; 78:351–345

23. Kandel E: Psychotherapy and the single synapse. the impactof psychiatric thought on neurobiologic research. N Engl JMed 1979; 301:1028–1037

24. Lambert MJ, Ogles BM: The efficacy and effectiveness of psy-chotherapy, in Bergin and Garfield’s Handbook of Psycho-therapy and Behavior Change, 5th ed. Edited by Lambert MJ.New York, John Wiley & Sons, 2004, pp 139–193

YAGER ET AL.


25. Mohl PC, Lomax J, Tasman A, et al: Psychotherapy trainingfor the psychiatrist of the future. Am J Psychiatry 1990; 147:7–13

26. Lehner GFT: Defining psychotherapy. Am Psychol 1952;7:547

27. http://www.acgme.org/downloads/RRC_progReq/400pr101.pdf28. Grant G et al (ed): On Competence: A Critical Analysis of

Competence-Based Reforms in Higher Education. San Fran-cisco, Jossey-Bass, 1979

29. National Organization for Competency Assurance www.NOCA.org

30. National Occupational Testing Institute www.nocti.org31. Goleman D: Working With Emotional Intelligence. New

York, Bantam Books, 199832. Margolis MJ, De Champlain AF, Klass DJ: Setting examina-

tion-level standards for a performance-based assessment ofphysician’s clinical skills. Acad Med 1998; 73(Oct/Nov suppl):S114–S116

33. Wass V, Ven der Vieuten C, Shatzer J, Jones R: Assessmentof clinical competence. Lancet 2001; 945–949

34. Southgate L, Hays RB, Norcini J, et al: Setting performancestandards for medical practice: a theoretical framework. MedEduc 2001; 35:474–481

35. Lurhmann TM: Of Two Minds. New York, Knopf, 2000

36. Mellman L, Beresin E: Psychotherapy competencies: develop-ment and implementation. Acad Psychiatry 2003; 27:149–153

37. Psychodynamic Psychotherapy Competency Test. http://psychotherapy.cursum.net

38. Mullen LS, Rieder RO, Glick RA, et al: Testing psychody-namic psychotherapy skills among psychiatric residents: ThePsychodynamic Psychotherapy Competency Test. Am J Psy-chiatry 2004; 161:1658–1664

39. Geller JS, Brown K, Zaitsoff S, et al: Collaborative versusdirective interventions in the treatment of eating disorders:implications for care providers. Professional Psychol: Res andPractice 2003; 34:406–413

40. Liston EH, Yager J, Strauss GD: Assessment of psychother-apy skills: the problem of interrated agreement. Am J Psy-chiatry 1981; 138:1069–1074

41. Caplow T: How to Run Any Organization. New York, Holt,Rinehart and Winston, 1976

42. Louisiana State Board of Examiners of Psychologists. http://www.lsbep.org/competencies_instructions.pdf

43. Savenkov O: Psychotherapy Training and Empirical Evidence:A Resident’s Conundrum, http://www.cpa-apc.org/Publications/Bulletin/current/residents.pdf

44. Borus JF, Yager J: Ongoing evaluation in psychiatry: the firststep toward quality. Am J Psychiatry 1986; 143:1415–1419

The RRC Mandate for Residency Programs to Demonstrate Psychodynamic Psychotherapy Competency Among...

Documents

Transcript of The RRC Mandate for Residency Programs to Demonstrate Psychodynamic Psychotherapy Competency Among...